By Reena Wadia, Principal & Specialist Periodontist, Len D'Cruz, Principal & Head of BDA Indemnity, and Linzy Baker, Dental hygienist & therapist

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The Coronavirus (COVID-19) global pandemic has posed significant challenges for all members of the dental team. Whilst dentists are considered to be one of the most exposed and high-risk occupations, dental hygienists and dental therapists are in fact at even greater risk.1 Dental hygienists and therapists are integral members of the dental team and play a key role in preventing, treating disease and maintaining oral health. Whilst we are uncertain on how the pandemic will affect the future of dentistry, we need to ensure that hygienists and therapists are kept at the forefront. There are almost six times as many dentists as hygienists2 so it's important to ensure the voice of hygienists and therapists is heard just as clearly as that of dentists.

Being off work for several months, uncertainty on when 'normal' clinical care will resume and what the new 'normal' may entail, has understandably led to well-founded concerns for hygienists and therapists. Although we are all looking forward to returning to some sort of normality and routine, the anxiety of going back to work remains. A survey,3 which included 917 responses from dental hygienists and therapists in the UK, asked how anxious they were about returning to work on a scale of 1 (not anxious) to 10 (extremely anxious). The average score was 6.9. Some of the results of the survey are shown in Figure 1, Figure 2 and Figure 3.

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'What are your main concerns at this time in terms of your job?'

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Fig. 2
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'Have you been successful in obtaining government-backed schemes/finance?'

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'Does your practice have enough and appropriate hand scalers that you would be okay to use?'

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The primary concern at this time appears to be financial (70%). There are a number of state backed schemes directed at the workforce including the Coronavirus Job Retention Scheme (CJRS) providing furloughed employees with 80% of their normal salary; the Coronavirus Business Interruption loan scheme which are government backed loans to practices, interest free for the first 12 months; and Self-employment Income support schemes for the self-employed whose trading profits were less than £50,000.

The survey indicated that the majority of hygienists (73%) have not been furloughed as they are self-employed, meaning practices are unable to pass on funding from the CJRS, which they have done for other employed dental team members. The financial concerns of many professions have been addressed through help from the government but worryingly only 21% of hygienists and therapists have been successful in obtaining a government-backed scheme or loans. It doesn't end there. What will be the financial implications for hygienists and therapists when they do return to work? If paid per patient or a percentage and fewer patients are treated through the day due to social distancing and downtime for surgery decontamination, income will clearly be affected. Depending on individual practice arrangements, hygienists and more probably therapists, who provided their services through the NHS, may have access to the NHS funding that continues to be paid to practices.

Finance was closely followed by concerns about appropriate personal protective equipment (PPE) (65%). Being at the highest risk, it's crucial the health and wellbeing of hygienists is considered. Although availability of appropriate PPE is improving, there is still a lack of FFP3 masks. Currently, only 8% of practices have made arrangements for FFP3 masks for hygienists and therapists, and only 3% have been fit tested. The need for FFP3 masks will depend on the treatment provided and current guidance advises it when carrying out aerosol generating procedures (AGPs).4 There are likely to be many other stringent requirements when it comes to PPE and cross infection. Use of the wide bore suction appears to be 90% effective in reduction of aerosols, but this would not be practical for hygienists or therapists to use effectively by themselves.5 So it is clear that hygienists and therapists currently working alone will need nursing support to meet these proposed requirements.

In the absence of a vaccine, a staged return to care is likely but how will this be approached clinically? The greatest risk comes from AGPs. These form a significant component of periodontal care provided by hygienists and therapists through use of ultrasonic instruments and technology such as Airflow. There are alternatives such as hand instrumentation which may be required in the interim. Although these are an effective alternative, treatment will take longer and may be more strenuous to the operator. From our survey, it was clear that there seem to be worries amongst hygienists and therapists about providing the same level of care with hand instrumentation only. Although more than half of hygienists and therapists would be happy to complete hand instrumentation for a limited period, if given a choice, a greater proportion would prefer to wait until appropriate PPE was available for them to use ultrasonic instruments. Either way, in the immediate future it will be important to ensure hygienists have hand instruments of sufficient quantity and quality. In our survey, just under half of hygienists and therapists felt practices had enough and appropriate hand instruments available.

Let's keep the well-being of our patients and teams at the very centre of our minds when we start making decisions about the future of dentistry.

There were many other comments from hygienists and therapists above and beyond financial, PPE and clinical issues. Morale is expectedly low across the profession and the need for clear guidance to reassure teams about a safe environment to return to work in is vital. It was concerning to see that a few were considering re-training or a career change. Right now, every available hygienist and therapist should be protecting patients' oral health but it is realistically going to be challenging managing both patients' and clinicians' expectations. Practices that fund their hygienist services under private contract may find these services less popular if the economic situation influences patients' spending priorities.6

During these challenging times everyone in dentistry needs to support each other. Let's learn to adapt to change and bounce back even stronger. Let's keep the wellbeing of our patients and teams at the very centre of our minds when we start making decisions about the future of dentistry.